CLM-2026-002882
Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Ann Lewis
- Member ID
- UHC-05814-43
- Date of birth
- 1960-10-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432616
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2024-07-01 to present
- Deductible
- $2,330.94 of $3,500.0067%
- Out-of-pocket maximum
- $1,630.58 of $10,500.0016%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5513308960
- Network
- In network
- Rendering NPI
- 7011021822
- Location
- Minneapolis, MN · TIN 38-7701279
- Authorisation / referral
- PA2025358983 / REF905881
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 29881 rev 0360 | Knee arthroscopy with meniscectomy | — | 1 | 1 | $10,721.00 | $5,896.55 | $2,114.56 | $3,781.99 | Paid |
| Totals | $10,721.00 | $5,896.55 | $2,114.56 | $3,781.99 | ||||||
- 1. S83.241A Other tear of medial meniscus, right knee, initial encounterprincipal
- Patient account
- PA-605946
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026949 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025358983 on file for 29881. | |
| Provider network | Pass | In-network provider Riverside Orthopedic Specialists (5513308960). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Orthopedic Specialists2026-03-27 16:25
Patient seen for other tear of medial meniscus, right knee, initial encounter.
Attachments
Documents received with the claim
- Prior auth letterPA2025358983_approval.pdf2 pages
Utilisation management approval letter for 29881 (Knee arthroscopy with meniscectomy), valid 2026-03-27 to 2026-06-25.
- Itemized billitemized_PA-605946.pdf7 pages
Itemised statement totalling $10721.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.